The Affordable Care Act & Non-Group Health Insurance

uninsured, limited, bankruptcy, expensive

Background: before the ACA

• around 20% of non-elderly adults were _________

• if not eligible for ESHI, Medicare, or Medicaid —> options were ________

• individual (non-group) insurance —> expensive, unreliable, excluded pre-existing conditions

• many faced medical _________ from uncovered costs

• rationale for reform: uninsured use ________ uncompensated ER/hospital care, driving up systemwide cost

mandates, subsidies, template

origins — MA reform 

• “Romneycare”

• ________: residents buy coverage (everyone including healthy); employers with more than 10 full-time workers provide it

• ________: free coverage for those making less than or equal o 150% FPL, sliding scale subsidies to those less than/equal to 300% FPL 

• reached around 98% insured —> served as _______ for the ACA

It demonstrated that mandates + subsidies + marketplaces could achieve near-universal coverage

obama

ACA signed into law

• patient protection & ACA signed 2010 by president _______

• comprehensive reform covering private, public & non-group markets

market reforms, mandates, subsidies

three-pronged structure, each “leg” necessary for stability — remove one —> collapse

1. _________ _________: create marketplaces to compare/buy plans; prohibit denials for pre-existing conditions; community-related premiums (only vary by age, tobacco, geography, family size) —> fix broken individual market

2. ___________:

   1. individual mandate where everyone must have coverage (penalty for none)

   2. employer mandate: large firms with more than 50 full-time employees must affordable coverage —> maintain balanced risk pool (avoid death spiral)

3. __________:

   1. make coverage affordable through Medicaid expansion (to those less than or equal to 138% FPL) and premium + cost-sharing subsidies (100-400% FPL) —> enable participation & affordability

denial, essential health benefits

major market reforms

• health insurance marketplaces (federal or state): “one-stop shop” for eligibility & plan comparison

• guaranteed issue & renewability: no _______ for health status

• modified community rating: restricts premium variation

• __________ ___________ __________ EHB: 10 required categories (ambulatory, emergency, hospitalization, maternity, mental health, Rx, rehab, labs, preventive, pediatric)

• allow family dependent coverage up to age 26

• can’t run out of coverage on EHBs no lifetieme/annual limits, OOP caps, free preventive care, medical loss ratio cap (insurers can’t keep more than a certain share of your premium for overhead or profit)

individual mandate, tax

the ____________ _____________ required everyone to have insurance or pay a ____ penalty

• exemptions: hardship, religious, undocumented

• penalty = $0 after 2019 (federal repeal)

• state mandates remain in CA DC MA, NJ, RI

• meant to pool risk

employer mandate, penalty, credit

the _____________ __________ (>=50 full time employees) said employers must offer affordable coverage and minimum value

penalties

• not offering coverage —> _______ of 2,900 per FT employee

• offering unaffordable coverage —> penalty of $4350 per FT employee receiving tax credit

govt. doesn’t require smaller firms to provide but to encourage, firms less than 25 full time employees with less than or equal to $56k average wage —> small business tax ______ via SHOP exchange

Medicaid, premium, cost-sharing

The ACA expanded ______ eligibility to more low-income adults for the first time since 1965.
This expansion became optional after the Supreme Court case NFIB v. Sebelius.
It also created ______ tax credits and ______ reductions to make marketplace coverage affordable.

Medicaid, minorities

After implementation, the uninsured rate fell dramatically.
The biggest driver of new coverage was ______ expansion, especially helping ______ and low-income adults.

mandate, tax, Medicaid

The Court upheld the individual ______ as a ______ but ruled that states could choose whether to expand ______.
Later, in King v. bURWELL, the Court upheld subsidies for federal marketplaces.

zero, cut, American Rescue Plan, Inflation Reduction Act

Under Trump, the federal mandate penalty was set to ______ and outreach funding was ______.
Under Biden, subsidies were expanded through the ______ ______ ______ and extended by the ______ ______ ______.

Medicaid, subsidies

The ACA helped stabilize coverage during the pandemic through expanded ______ and marketplace ______.

highest

The uninsured rate remains about half of what it was before the ACA, and marketplace enrollment is at a record high.
Public support for the ACA is now the ______ in its history.

reforms, mandate, subsidies

The ACA is built on three pillars: market ______ to protect the sick, an individual ______ to bring healthy people in, and income-based ______ to make coverage affordable.